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Based on document review and interview, the facility failed to utilized its Quality Assurance and Performance Improvement (QAPI) program to analyze data collected on patient elopements in the Emergency Department (ED) and implement action plan to ensure patients' safety.

This failure places patients at risk for harm.

Findings include:

Review of the ED QAPI minutes from September 2018 to June 2019 revealed the facility had 41 elopements in the ED as follows:

September 2018=11
October 2018=5
December 2018=6
January 2019=3
February 2019=2
March 2019=4
April 2019=0
May 2019=7
June 2019=3

There was no documented evidence in the ED QAPI minutes that elopements were analyzed, trended, and corrective action plan implemented to address identified problems.

During interview on 9/17/19 at 10:05 AM, Staff K, Chief Medical Officer/Quality Assurance Officer, Staff J, Vice President of Operations, and Staff L, Regulatory Director reported that they have not analyzed the September 2018 to June 2019 elopement data, and the QAPI related to elopement has not been presented to the Medical Board and Quality Safety Committee.

Based on medical record review, document review and interview, in two (2) of thirteen (13) medical records reviewed, the facility failed to implement its Emergency Department policies and procedures to ensure patients with elopement risk were placed on elopement precautions to ensure their safety (Patient #s 1 and 2).

This failure places patients at a potential risk for harm.

Findings include:

See Tag A1104.

Based on medical record review, document review and interview, in two (2) of thirteen (13) medical records reviewed, the facility failed to implement its Emergency Department (ED) policies and procedures to ensure patient with elopement risk were placed on elopement precautions to ensure their safety (Patient #s 1 and 2).

This failure places patients at a potential risk for harm.

Findings include:

Review of the facility's policy and procedure titled "Elopement," last revised in December 2017 stated the following:

...In the Emergency Department, the triage nurse and/or clinical staff determining the patient is high-risk for elopement will communicate to the charge nurse and Registered Nurse (RN) the patient's high-risk status (elopement, suicidal/homicidal, falls, cognitive impairment, and others). The charge nurse will follow-up and ensure an ancillary staff is place with the patient and all personal items including clothing are removed and sent to Security.
-The charge nurse ensures the patient is placed in a green hospital gown until deemed competent by psychiatry or an ED physician.
-During hand-off, the ED informs the receiving nurse via written documentation as well as verbally.

Review of the medical record for Patient #1 identified a 58-year old male, nursing home resident who was triaged in the ED on 7/26/29 at 11:12 AM for psychiatric evaluation due to aggression and violent outbursts in the nursing home. The patient was assessed to be calm and cooperative. He denied homicidal and suicidal ideation. The patient's past medical history included anxiety, paranoia (irrational thought process of suspicion and mistrust). The triage nurse documented a history of elopement and he was assessed as a high risk for elopement.

Review of the Ambulance Call Report (ACR) dated 7/26/19 noted the patient was alert and oriented to person and place but was confused. As per nurse in the nursing home, the patient was a danger to self and others.

On 7/26/19 at 12:29 PM, the ED Physician Assistant (PA) documented a "priority stat order" for a psychiatric consultation. The reason for the consultation was worsening paranoia and aggression in the nursing home.

On 7/26/19 at 4:19 PM, ED physician discharge note indicated that the patient left without medical examination; the patient was not in bed at 12:40 PM, and he did not respond to overhead paging.

There was no documented evidence that this patient who was assessed as a high risk for elopement, was placed on elopement precautions. An ancillary staff was not assigned to monitor the patient as per he elopement policy.
There was no indication that the patient was placed in a green hospital gown until deemed competent by the psychiatrist or ED physician.

During interview on 9/13/19 at 10:37 AM, Staff A, ED Triage RN stated she flagged the patient as a high risk for elopement; however, she did not place the patient on elopement precautions because during her encounter with the patient, he was alert and oriented.

During interview on 9/16/19 at 10:13 AM, Staff C, ED Physician Assistant (PA) reported the patient had aggressive behavior in the nursing home, and the patient had dementia. During her encounter with the patient, he was in street clothes. She stated the patient should have been placed on 1:1 observation for increased level of observation, and in a green gown.

During interview on 9/16/19 at 10:47 AM, Staff B, ED RN acknowledged that the patient was a high risk for elopement but he did not place the patient on elopement precautions because he responded appropriately to questions, he followed commands, and he did not trigger any suspicion for elopement.


Review of the medical record for Patient #2 revealed a 52-year old female from a group home who was triaged on 7/25/19 at 2:38 PM for psychiatric evaluation. The patient was alert and oriented to person, place and time, and denied harm to self. The patient had history of psychiatric illness, diabetes and hypertension and was non-compliant with medications. The triage note indicated the patient had no history of elopement; however, the elopement assessment revealed she was a high risk.

On 7/25/19 at 7:45 PM at 8:27 PM, ED Attending Physician discharge note indicated the patient was not found in bed at 5:00 PM.

There was no documented evidence the patient was placed on elopement precautions and that an ancillary staff was assigned to monitor the patient. There was no indication the patient was placed in a green hospital gown until deemed competent by the psychiatrist or ED physician.

During interview on 9/16/19 at 11:20 AM, Staff F, ED Triage Nurse stated she did not place the patient on elopement precautions because during triage the patient was calm and cooperative, the patient was not aggressive towards her, she had no suicidal and homicidal ideation, and she answered all questions appropriately.

During interview with Staff G, ED RN on 9/16/19 at 11:57 AM, the patient was not on elopement precaution when she received the patient after she was triaged and her risk for elopement was not communicated to her. During her encounter with the patient, she was not agitated and was not deemed and elopement risk.